DCA17FA021

NTSB accident investigation · Boeing 767 · Chicago, IL · October 28, 2016

Accident · Serious injuriesClass 1 · FieldFinal report
Date
October 28, 2016
Place
Chicago, IL
Injuries
1 serious, 20 minor, 149 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N345ANBoeing 767
Defining event
Takeoff-rejected takeoff: Uncontained engine failure
Weather
Visual (VMC) · Day
Status
Completed · report February 6, 2018
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
20161028021359A
Case key
94308

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The failure of the high-pressure turbine (HPT) stage 2 disk, which severed the main engine fuel feed line and breached the right main wing fuel tank, releasing fuel that resulted in a fire on the right side of the airplane during the takeoff roll. The HPT stage 2 disk failed because of low-cycle fatigue cracks that initiated from an internal subsurface manufacturing anomaly that was most likely not detectable during production inspections and subsequent in service inspections using the procedures in place. Contributing to the serious passenger injury was (1) the delay in shutting down the left engine and (2) a flight attendant's deviation from company procedures, which resulted in passengers evacuating from the left overwing exit while the left engine was still operating. Contributing to the delay in shutting down the left engine was (1) the lack of a separate checklist procedure for Boeing 767 airplanes that specifically addressed engine fires on the ground and (2) the lack of communication between the flight and cabin crews after the airplane came to a stop.

Findings · 10

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine (turbine/turboprop): turbine sectionAircraft › Aircraft power plant · FailureBoeing 767-323: 1 caseAll aircraft: 74 casesProbable cause
Fuel systemAircraft › Aircraft systems · Damaged/degradedBoeing 767-323: 1 caseAll aircraft: 181 casesProbable cause
Use of equip/info: use of policy/procedurePersonnel issues › Task performance · Cabin crewBoeing 767-323: 1 caseAll aircraft: 191 casesProbable cause
Action: delayed actionPersonnel issues › Action/decision · Flight crewBoeing 767-323: 1 caseAll aircraft: 894 casesProbable cause
Communication (personnel): lack of communicationPersonnel issues › Task performance · Flight crewBoeing 767-323: 1 caseAll aircraft: 84 casesProbable cause
Communication (personnel): lack of communicationPersonnel issues › Task performance · Cabin crewBoeing 767-323: 1 caseAll aircraft: 84 casesProbable cause
Manufacture/production: equipment manufactureOrganizational issues › Development · ManufacturerBoeing 767-323: 1 caseAll aircraft: 36 casesProbable cause
Design: task designOrganizational issues › Development · ManufacturerBoeing 767-323: 1 caseAll aircraft: 3 casesProbable cause
Training: emergency proc trainingOrganizational issues › Support/oversight/monitoring · FAA/RegulatorBoeing 767-323: 1 caseAll aircraft: 8 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report. The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/01. On October 28, 2016, about 1432 central daylight time, American Airlines flight 383, a Boeing 767-323, N345AN, had started its takeoff ground roll at Chicago O'Hare International Airport, Chicago, Illinois, when an uncontained engine failure in the right engine and subsequent fire occurred. The flight crew aborted the takeoff and stopped the airplane on the runway, and the flight attendants initiated an emergency evacuation. Of the 2 flight crewmembers, 7 flight attendants, and 161 passengers on board, 1 passenger received a serious injury and 1 flight attendant and 19 passengers received minor injuries during the evacuation. The airplane was substantially damaged from the fire. The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121. Visual meteorological conditions prevailed at the time of the accident.

Factual narrative

The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/01. On October 28, 2016, about 1432 central daylight time, American Airlines flight 383, a Boeing 767-323, N345AN, had started its takeoff ground roll at Chicago O'Hare International Airport, Chicago, Illinois, when an uncontained engine failure in the right engine and subsequent fire occurred. The flight crew aborted the takeoff and stopped the airplane on the runway, and the flight attendants initiated an emergency evacuation. Of the 2 flight crewmembers, 7 flight attendants, and 161 passengers on board, 1 passenger received a serious injury and 1 flight attendant and 19 passengers received minor injuries during the evacuation. The airplane was substantially damaged from the fire. The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121. Visual meteorological conditions prevailed at the time of the accident.

Aircraft

Registration
N345AN
Reported as
Boeing 767 (323)
Category
Airplane
Serial number
N345AN
Built
2003
Engines
General Electric CF6-80C2 B6, turbo fanGeneral Electric CF6-80C2 B6, turbo fan
Damage
Substantial damage
Fire
On-Ground
Flight
Part 121
Operator
American Airlines Inc
Registered owner
American Airlines Group, Inc.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · January 15, 2011
Departed
KORD · Chicago, IL
Destination
KMIA · Miami, FL
Flight plan
IFR
Airport
KORD · Chicago O'Hare International A, runway 28R, 13,000 × 150 ft, concrete
Equipment
Electronic flight bag or handheld device, Data recorder, Stall warning system, Electronic multifunction display

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
61
Injuries
None
Certificates
Flight engineer, Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
March 22, 2016
Seat
Left
Restraint
3-point
Flight hours
17,400 total · 4,000 in this make and model
Role
Co-pilot
Age
57
Injuries
None
Certificates
Flight engineer, Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
September 7, 2016
Seat
Right
Restraint
3-point
Flight hours
22,000 total · 1,846 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 11 knots
Visibility
10 statute miles
Lowest ceiling
25,000 ft overcast
Temperature
61 °F, dew point 52 °F
Altimeter
30.04 inHg
Observed at
KORD

Docket · 51

The files NTSB released with the investigation on July 6, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 865 MB in all.

Airworthiness group chairmana��s factual reportItem 1 · PDF · 61 pages · 9.2 MBAirworthiness, attachment 1 to factual reportItem 2 · PDF · 10 pages · 4.9 MBAirworthiness, attachment 2 to factual reportItem 3 · PDF · 21 pages · 4.0 MBAirworthiness, attachment 3 to factual reportItem 4 · PDF · 2 pages · 14.6 MBOperational factors/human performance group chairmen's factual reportItem 5 · PDF · 42 pages · 941 KBOperational factors/human performance factual attachment 1 - flight crew interview summariesItem 6 · PDF · 16 pages · 423 KBOperational factors/human performance attachment 2 - flight crew written statementItem 7 · PDF · 3 pages · 570 KBOperational factors/human peformance attachment 3 - American airlines personnel interviewsItem 8 · PDF · 36 pages · 341 KBOperational factors/human performance attachment 4 - simulator and cockpit evaluationItem 9 · PDF · 17 pages · 649 KBOperational factors/human performance attachment 5 - o'hare airport chartsItem 10 · PDF · 5 pages · 233 KBOperational factors/human performance attachment 6 - American airlines pilot flight recordsItem 11 · PDF · 9 pages · 337 KBOperational factors/human performance attachment 7 - American airlines flight operations training manual [excerpt]Item 12 · PDF · 6 pages · 101 KBOperational factors/human performance attachment 8 - American airlines flight attendant briefingItem 13 · PDF · 2 pages · 60 KBOperational factors/human performance attachment 9 - American airlines takeoff briefingItem 14 · PDF · 2 pages · 72 KBOperational factors/human performance attachment 10 - rejected takeoff proceduresItem 15 · PDF · 3 pages · 87 KBOperational factors/human performance attachment 11 - American airlines engine fire, severe damage, or separation checklistItem 16 · PDF · 4 pages · 169 KBOperational factors/human performance attachment 12 - American airlines evacuation checklistItem 17 · PDF · 2 pages · 85 KBOperational factors/human performance ATTACHMENT13 - American airlines evacuation decision and dutiesItem 18 · PDF · 5 pages · 95 KBOperational factors/human performance attachment 14 - operation manual checklist informationItem 19 · PDF · 11 pages · 113 KBOperational factors/human performance attachment 15 - American airlines crew authorityItem 20 · PDF · 4 pages · 86 KBOperational factors/human performance attachment 16 - Boeing rejected takeoff decision makingItem 21 · PDF · 7 pages · 132 KBOperational factors/human performance attachment 17 - Boeing rejected takeoff procedureItem 22 · PDF · 5 pages · 475 KBOperational factors/human performance attachment 18 - Boeing flight manual - engine fire, severe damage or separtation checklistItem 23 · PDF · 4 pages · 59 KBOperational factors/human performance attachment 19 - Boeing qrh - engine fire, severe damage or separation checklistItem 24 · PDF · 4 pages · 316 KBOperational factors/human performance attachment 20 - Boeing evacuation checklistItem 25 · PDF · 2 pages · 99 KBOperational factors/human performance attachment 21 - non-normal checklist instructionsItem 26 · PDF · 3 pages · 390 KBOperational factors/human performance attachment 22 - American airlines Airbus engine fire checklist (on ground)Item 27 · PDF · 5 pages · 256 KBOperational factors/human performance attachment 23 - American airlines Embraer engine fire checklist (on ground)Item 28 · PDF · 6 pages · 525 KBSurvival factors - survival factors group chairmana��s factual reportItem 29 · PDF · 24 pages · 6 photos · 1.6 MBSurvival factors attachment 1 a�� flight attendant interviewsItem 30 · PDF · 27 pages · 163 KBSurvival factors attachment 2 a�� passenger interviewsItem 31 · PDF · 3 pages · 78 KBSurvival factors attachment 3 a�� American airlines management interviewsItem 32 · PDF · 12 pages · 115 KBSurvival factors - attachment 4 a�� terminal video of evacuation (1)Item 33 · MOV · 288 MBSurvival factors attachment 5 - terminal video of evacuation (2)Item 34 · MOV · 16.2 MBMaterials laboratory factual report 17-034Item 35 · PDF · 81 pages · 63 photos · 33.4 MBMaterials laboratory study report 17-034SItem 36 · PDF · 6 pages · 4 photos · 291 KBFlight data recorder specialist's factual reportItem 37 · PDF · 15 pages · 3.3 MBFlight data recorder specialist's factual report - attachment 1Item 38 · CSV · 2.9 MBGeneral electric metallurgical investigation report FA2017-18058 metallurgical evaluation of ati 718 billet dws findingsItem 39 · PDF · 4 pages · 826 KBPowerplant group chairman's factual reportItem 40 · PDF · 77 pages · 8.6 MBCockpit voice recorder - group chairman's factual reportItem 41 · PDF · 15 pages · 253 KBAmerican airlines party submissionItem 42 · PDF · 10 pages · 169 KBApa party submissionItem 43 · PDF · 9 pages · 60 KBApfa party submissionItem 44 · PDF · 4 pages · 403 KBAti party submissionItem 45 · PDF · 7 pages · 75 KBBoeing party submissionItem 46 · PDF · 10 pages · 155 KBGe party submissionItem 47 · PDF · 2 pages · 58 KBTwu party submissionItem 48 · PDF · 1 page · 289 KBFlight data recorder specialist's factual report - errata 1Item 49 · PDF · 1 page · 10 KBErrata to CVR group chairman's factual reportItem 50 · PDF · 1 page · 10 KBVideo file provided by chicago department of aviation airport operationsItem 51 · M2TS · 468 MB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.